DSM 5 Total Diagnoses Revealed

As any reader of this blog can recall one of my foci is to expose the anti DSM 5 rhetoric for what is was.  One the the main points by DSM detractors was diagnostic proliferation or more total diagnoses.  This implies more diagnoses, more prescriptions, and more money for psychiatrists and pharmaceutical companies.  Another spin was that it was the intent of organized psychiatry to "pathologize" the population.  I put up a table on this issue in a previous post and at that time did not have the final number of diagnoses.  As of today I have the final number and it is 157.  According to the presenter that means that a total of 15 diagnoses were eliminated from DSM-IV to DSM 5.  The total diagnoses in DSM 5 did not increase as the detractors predicted - they decreased by 15.

I was at a conference today put on by the University of Wisconsin Department of Psychiatry entitled Annual Update and Advances In Psychiatry.  The Introduction by Art Walaszek, MD acknowledged that this was the first in a series that replaces a long tradition of courses run by John H. Greist, MD and James W. Jefferson, MD: "Jeff Jefferson and John Greist ran this conference for 31 years."  That is an amazing track record and record of achievement and a contribution to psychiatry in the Midwest.  I don't know of many psychiatrists who were not aware of this conference with the alliterative titles like:  "Quaffing Quanta of Quality from Quick Witted Quinessentialists" or the Door County Course they regularly taught.  They have been a model of scholarship and professionalism and continue to be.

The first speaker today was Alan Schatzberg, MD.  He posted the information about the total diagnostic categories in DSM 5 an other important changes and how they occurred.  Per my previous post about the DSM 5 lectures by Jon Grant, MD the DSM 5 effort was outlined in addition to some critical information on how stigma affects psychiatric diagnosis.  For example, when the DSM 5 work group wanted to add mild neurocognitive disorder a well known historian of psychiatry came out and said it would add countless people who had normal memory impairment associated with aging.  When neurologists added mild cognitive disorder to their diagnostic nomenclature (an equivalent diagnosis) no such claims were made about neurologists.  In terms of the effort, Dr. Schatzberg pointed out that there were 13 conferences from 2003-2008 that produced 10 monographs and over 200 journal articles.

Dr. Schatzberg and his colleagues presented a ton of information today on what really happened with DSM 5 development.  I will try to summarize and post additional comments when I can post from a more user friendly computer.  I wanted to keep the post more on the scientific and debunk another common refrain from the naysayers before the DSM 5 was printed.  That involved the so called "bereavement exclusion" that basically says that a person cannot be diagnosed with major depression if they are seen during an episode of grief.  One question that was never brought up in the popular press "Where did this convention came into the diagnostic criteria in the first place?"  I quoted a text from about the same time (see third from last paragraph) that makes this convention seem even more arbitrary.  It turns out the original bereavement exclusion began in DSM-III not from any research basis but from convention that was subjectively determined by the authors of DSM-III.  Contrast that with the research done by Zisook,  et al. You would think that some of the self proclaimed level headed skeptics out there would have referred to this critical paper on the issue rather than speculative attacks on the field.  Incorporating these scientific findings was one of the reasons that the DSM was updated.

Stay tuned for more of the hard data and insider info on DSM 5.

George Dawson, MD, DFAPA

1: Zisook S, Corruble E, Duan N, Iglewicz A, Karam EG, Lanouette N, Lebowitz B, Pies R, Reynolds C, Seay K, Katherine Shear M, Simon N, Young IT. The bereavement exclusion and DSM-5. Depress Anxiety. 2012 May;29(5):425-43. doi: 10.1002/da.21927. Epub 2012 Apr 11. Review. Erratum in: Depress Anxiety. 2012 Jul;29(7):665. PubMed PMID: 22495967.

Supplementary 1:  The DSM-5 Guidebook by Donald W. Black, MD and Jon E. Grant, MD came out in March 2014.  Table 1.  (p.  xxiii) lists the total diagnoses is DSM-5 as 157 excluding "other specified and unspecified disorders". 

Moralizing About Psychiatry and the Limits of Philosophy

This article came to my attention this week from the New York Times blogs.  The author identifies himself as a philosophy professor and scholar who is an expert in French philosophy.  He presents some viewpoints of Foucault and others to criticize the DSM and of course the clinical method in psychiatry.  I will be the first to admit his initial argument is confusing at best and is based on Foucault’s observation: “What we call psychiatric practice is a certain moral tactic….covered over by the myths of positivism.”  Indeed, what psychiatry represents as the “liberation of the mad” (from mental illness) is in fact a “gigantic moral imprisonment.”  In the next sentence the author  acknowledges: "Foucault may well be letting his rhetoric outstrip the truth, but his essential point requires serious consideration."

From my viewpoint whenever an author’s rhetoric outstrips the truth it means that at the bare minimum any observer should be skeptical of the biases involved and these appear to be the common themes that we see from antipsychiatrists.  It does not take the author very long to develop that angle:

“Psychiatric practice does seem to be based on implicit moral assumptions in addition to explicit empirical considerations, and efforts to treat mental illness can be  society’s way of controlling what it views as immoral or otherwise undesirable behavior.”

He gives examples of the previous treatment of homosexuality and women and uses this as a platform for suggesting “….there’s no guarantee that even today psychiatry is free of similarly dubious judgments.”  With no credit given to Spitzer’s role in both the DSM and eliminating homosexuality as a mental illness back in the 1970’s (where is the rest of America on that issue even today?) he latches on to the bereavement exclusion as the latest example of how psychiatrists are trying to dictate how people live and how various nonphysicians are better equipped to decide about whether the bereavement exclusion should be left in place.  Like every other commentator he waxes rhetorical himself using the well worn descriptor “medicalization” and suggesting part of the motivation for these changes is pressure from the pharmaceutical industry.  I recently posted a response to a less well written criticism from the Washington Post that addresses these issues and I would encourage anyone interested in finding out what is really going on to take a look at that post.

The question here is what have Professors Foucault and Gutting missed in their critiques about psychiatry?  It turns out they have missed a lot. The first obvious flaw is the misinterpretation about the role of psychiatric diagnosis and a diagnostic manual for psychiatrists.  The DSM (or any technical diagnostic manual) does not represent a blueprint for living and there is no psychiatrist who has ever made that claim.  This error is promulgated in the media by referring to the DSM as a "bible".  In fact, it is not a bible or blueprint for living.  Psychiatrists more than anyone realize that they are addressing a small spectrum of human behavior with the goal of alleviating suffering and restoring function.  The second flaw is that changing a diagnostic criteria in a DSM has any meaning with regard to treatment and diagnosis.  In the case of bereavement that ignores the fact that only a tiny fraction of patients with complicated bereavement or depression ever come to the attention of a psychiatrist.  Grief is a normal human reaction and everybody knows it.  Taken to an absurd level – if organized psychiatry said that everyone with grief needed to take an antidepressant for the simple fact that “we have special knowledge about how people should live”  we would have no credibility at all.  People everywhere know that grief is common and expected and severe mental illnesses are not.  At that level psychiatry is an extension of the common man’s psychology.  The third flaw has to do with impairment.  A diagnosis can be made only with an impairment dimension.  From DSM-IV:

“In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e. impairment in one or more areas of functioning) or with significantly increased risk of suffering, death, pain, disability or an important loss of freedom.  In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one.” – DSM-IV

The critics never acknowledge that like all physicians, a psychiatrist’s role is to treat illness and alleviate suffering.  Further, the clinical method in psychiatry is the only specialty training that emphasizes clinical neutrality and recognizing emotional and intellectual biases that impact the physician patient relationship and offers ways to resolve them.  That is hardly a model for forcing value judgments about preferred mental states on people who other physicians are frequently unable to treat because of their own value judgments.

The author also erroneously concludes that it is dangerous to make psychiatrists “privileged judges of what syndromes should be labeled mental illnesses” based on the fact that “they have no special knowledge about how people should live”.   Since psychiatrists do not make that claim, and since various groups including governments and religious institutions have been making these judgments for centuries with very poor results, I would suggest that psychiatry has had some problems – but the progress here is undeniable.  That makes psychiatrists experts in their own field in their own field and the purveyor of their own diagnostic methods and not a claim that people should live in a particular way.  DSM-IV takes pains to point out that it is classification system for syndromes and NOT people.  The DSM is not designed for an untrained person to look at and make a diagnosis or get guidance for living.  It is designed to be a common language for psychiatrists who have all had standardized training.

I would also like to suggest that the same philosophical criteria be seriously applied by philosophers to the pressing problems within the health care system.  The DSM is not even a gnat on that landscape.  We have had nearly 30 years of active discrimination by governments and insurance companies against persons with mental illness.  While much criticism has been heaped on the bereavement exclusion criteria, people with addictions and serious mental illnesses are routinely denied potentially lifesaving interventions.  This discrimination has been well documented and it has fallen disproportionately on the mentally ill.  Jails and prison have become de facto mental hospitals.  People are being treated with addicting drugs on a large scale to the point that many consider opiate use and deaths from overdose to be an epidemic.  Governments save money and pharmaceutical companies and the managed care cartel prosper.  Contrary to the author’s suggestion that “psychiatrists are more than ready to think that just about everyone needs their services” psychiatrists are rare and access is strictly controlled by managed care companies and the government.  Even if a person sees a psychiatrist, their medications, access to psychotherapy, and access to hospital treatment are all dictated by a business entity rather than their doctor.

It would seem that philosophers could find something to critique in that glaringly bleak health care landscape other than a trivial change in the diagnostic manual of a vanishing medical specialty.   If not, I would be very skeptical  of their arguments.

George Dawson, MD, DFAPA

Gary Gutting.  Depression and the Limits of Psychiatry.  New YorkTimes February 6, 2012.

Fulford KWM, Thornton T, Graham G.  Oxford Textbook of Philosophy and Psychiatry.  Oxford University Press, Oxford, 2006: 17.

"Some of the main models advanced by antipsychiatrists, mainly in the 1960s and 1970s, can be summarized thus:
1.  The psychological model...
2.  The labeling model...
3.  Hidden meaning models...
4.  Unconscious mind models...
5.  Political control models..." <-Foucault is located here. (p. 17)

Shorter E.  A History of Psychiatry.  John Wiley & Sons, New York, 1997: 302.   

"By the early 1990, DSM-III, or the revised version that appeared in 1987 (DSM-III-R), had been translated into over 20 languages. French psychiatry residents, initially taken with antipsychiatry and the doctrines of Jacques Lacan and Michel Foucault, began memorizing the 4 criteria (and 18 possible symptoms) 6 of which must be present for anxiety disorder." (Shorter: p 302) 


Addendum:

I made this interesting discovery several years after the original post (on May 22, 2019). Dr. Gutting has a chapter on Michel Foucault in the Stanford Encyclopedia of Philosophy and this is very consistent with his flawed analysis of the DSM-5.  Link.

A Psychiatrist Reads the Washington Post

There are an endless number of ways that the appearance of conflict of interest can be spun to make any organization look bad.  The obvious question is why that always seems to occur with psychiatry?  The arguments all follow the general form that a financial benefit resulting from work related to the pharmaceutical industry disqualifies those experts from writing objective research about medication or rendering opinions about the treatment of psychiatric disorders in general. That is the theme of the latest article from The Washington Post entitled “Antidepressants treat grief? Psychiatry panelists with ties to drug industry say yes."  It is an old story with little variation and I add some commentary based on the organization of the article.

"In what some prominent critics have called a bonanza for drug companies, the American Psychiatric Association this month voted to drop the old wording against diagnosing depression in the bereaved, opening the way for more of them to be diagnosed with major depression and thus, treated with antidepressants.”

This statement assumes that this practice is not occurring right now. In fact, it is widely known that the diagnosis of depression is not rigorously made in primary care settings. It is highly likely right now that patients suffering from grief as well as psychological adaptations to acute stress are being treated with antidepressants. There is no reason to believe that the patients being treated in primary care resemble the patients with a diagnosis of major depression in clinical trials of antidepressants.

"The change in the handbook, which could have significant financial implications for the $10 billion  US antidepressant market, was developed in large part by people affiliated with the pharmaceutical industry, an examination of financial disclosures shows.”

The previous statement talks about a "bonanza for drug companies" and builds on this image in the second statement. It ignores the fact that most commonly prescribed antidepressants are currently generics and available for as little as four dollars per month. The only two major antidepressants at this time that are not generics are Cymbalta (duloxetine) and Vibryd (vilazodone).  Where does the "10 billion dollar" figure come from?  If you read the entire article on page 5, that figure was from IMS America a company that tracks total prescriptions from American retail pharmacies.  Anyone knowing the applications for antidepressants would know that they are prescribed for many conditions other than depression including headaches, hot flashes, and chronic pain. The total retail sales figure is unlikely to reflect either drug company profits or the amount of depression being treated.

A little arithmetic is always instructive. If we assume that a physician prescribes a generic antidepressant for a patient that costs four dollars per month that translates to a total cost of $48 per year. The $10 billion/year figure quoted here would represent 208 million prescriptions or 66% of the entire population of  the U.S. taking antidepressants 12 months out of the year.  Even if we take $2 billion out of the $10 billion figure for Cymbalta and Vibryd, that results in 53% of the population taking antidepressants 12 months out of the year. Those figures are 5-8 times higher than any actual estimation of antidepressant use.  The $10 billion dollar figure is certainly eye-opening but there is plenty of evidence that it is not remotely accurate and will not have the purported impact on the pharmaceutical industry.

"About 80% of the prescriptions for antidepressants are written by primary-care physicians and others, not psychiatrists, a fact that makes the APA handbook particularly important. Faced with a patient complaining of depression-like symptoms, a general practitioner may be likely to rely on the Association's handbook for advice.”

This statement reveals the authors lack of knowledge about the practice of medicine and about the DSM that he is criticizing. The DSM is strictly a diagnostic manual and it contains no treatment recommendations. Primary care physicians are not avid readers of the DSM and that has probably led to the practice of using a DSM-based checklist – the PHQ-9.  This practice has not been promoted by the APA or the pharmaceutical industry (although the PHQ-9 is copyrighted by Pfizer pharmaceuticals).  Using a checklist to make a rapid diagnoses (in minutes) and rapidly treat large numbers of patients is promoted by managed care organizations and HMOs. That is probably the single greatest factor contributing to antidepressant prescriptions but it is ignored by the author - probably because it challenges his contention that this is all driven by conflict of interest in psychiatry rather than the business world.  It is cheaper for HMOs to treat depression with medications rather than detailed psychiatric assessments and psychotherapy.

"The Association itself runs on a budget of about 50 million a year, and for years industry funding has been critical to its operations. Today, about 14% of the Association's budget comes from pharmaceutical companies, mainly in the form of advertising at annual meetings and publications."

The author does a good job of providing no context here. Is the APA any different from other medical specialty organizations? Does advertising create a conflict of interest? Is any other print media outlet held to that standard? There is information available in those areas.   An Institute of Medicine report focused on conflict of interest showed that the APA's revenue from the pharmaceutical industry was in the middle of the pack with regard to medical specialty societies. As an example, the year that report was done the APA reported that medical companies supplied 28% of their annual income.  The American Academy of Family Physicians reported that 42% of their annual income was from pharmaceutical companies (p 220).  That same report (Recommendation 6.1) noted that increasing work for the pharmaceutical industry correlated with a 7% reduction in real physician wages and recommended that there was nothing wrong with “consulting arrangements based on written contracts for expert services to be paid for at fair market value”.   Depending on the expert involved, restricting the amount to $10,000 per year could practically mean anywhere from 2 to 10 presentations per year or about 2 1/2 weeks of contract work. 

“Other members of the committee have numerous ties to drug companies, too, and not simply conducting research, according to disclosures from last year. One was holding stock in Glaxo Smith Kline, one was a consultant to Servier and another consultant to Pfizer;  one had a grant from AstraZeneca and another a grant from Pfizer and AstraZeneca.”

This is a paragraph from a poorly written section illustrating ties between the 11 member Mood Disorders Work Group set up to draft the guidelines on major depression. There is some explanation of the selection criteria and conflict of interest criteria.  It discusses conflictof interest criteria that the APA designed and made explicit in response to this article.  It provides no context other than an off hand remark by the chairman that he probably regrets making. The article provides no reasonable context for expected reimbursement for experts as consultants to industries or the fact that this is a common practice in many academic departments on any major university campus. In some of those industries, the professional organizations actually make an effort to make sure that businesses are well represented in any process that involves making standards.

"The current handbook-the revised version will be published in the Spring-recommended against diagnosing major depression in the bereaved when the symptoms are milder and of less than two months duration. This is known as the "bereavement exclusion".  (If the signs of depression are severe-the patient has thoughts of suicide, for example-major depression is supposed to be diagnosed)….. The new handbook removes the bereavement exclusion."

There is really nothing new and nothing drastic as anticipated with removing the "bereavement exclusion". To provide a clear example I will quote a text copyrighted in 1982:

"There are many publications that deal with treating psychiatric patients who report recent and remote bereavement. It is possible to find a real or imagined loss in every patient's past. However, for the most part, because there is little evidence from reviewing normal bereavement that there is a strong correlation between bereavement and first entry into psychiatric care, those bereaved who are seen by psychiatrists should be treated for their primary symptoms. This is not to say that the death should not be discussed, but because these people represent a very small subset of all recently bereaved, they should be treated like other patients with similar symptoms but no precipitating cause. A physician seeing a recently bereaved with newly discovered hypertension might delay treatment one or two visits to confirm its continued existence, but treat it if it persists. So the psychiatrist should treat the patient with affective symptoms with somatic therapy but only if the symptoms are major and persist unduly. A careful history of past and present drug and alcohol intake is indicated. Then, the safest and most appropriate drugs to use are the antidepressants. Electroconvulsive therapy is indicated in the suicidal depressed." (Paykel p413-414).

Any psychiatrist worth his or her salt knows the difference between grief and depression and they should know the literature on treating grief, the natural history of grief, and the research on proven non-medical treatment of grief including Interpersonal Psychotherapy (IPT) and grief counseling. When you are seeing a psychiatrist, you are seeing an expert who should know the literature on grief, depression, and the differential diagnosis of depression.  Nothing in this article indicates that.  In fact, quotes are provided to suggest that the APA and psychiatry in general has an interest in redefining “the range of acceptable emotion” rather than using clinical research done by psychiatrists to limit suffering and prevent suicide.

I think the reality here indicates that there is no scandal.  The importance of the DSM-5, the appearance of conflict of interest, and the potential windfall for the pharmaceutical industry appear to be seriously overestimated.  Organized psychiatry is certainly not responsible for what happens  in primary care clinics under the direct guidance of business organizations.  There is a responsibility to establish professional standards for patients referred to psychiatrists for the assessment and treatment of complicated depressions that may occur during bereavement. The suggestion that medications may be useful in some of these situations and the importance of treating depression in bereavement has been around for at least 30 years.

George Dawson, MD, DFAPA

Peter Whoriskey.  Antidepressants to treat grief? Psychiatry panelists with ties to drug industry say yes. The Washington Post, December 26, 2012.

Clayton PJ. Bereavement in Handbook of Affective of Disorders.  Eugene S. Paykel (ed). The Guilford Press. New York. 1982  pages 413-414.

APA Reiterates Stringent Rules on Accepting Pharma Support.  Psychiatric News.  Monday December 31,2012.

Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice; Lo B, Field MJ, editors. Conflict of Interest in Medical Research, Education, and Practice. Washington (DC): National Academies Press (US); 2009. Available from: http://www.ncbi.nlm.nih.gov/books/NBK22942/